DSM-5 Substance Use Disorder Criteria...DECISION MAKING JUDGMENT PROBLEM SOLVING EMOTION SHORT TERM...

Protective

Capacities

ADDICTION:

WHAT HAPPENS TO

ADULT FUNCTIONING

AND PROTECTIVE

CAPACITIES WHEN

DRUGS HIJACK THE

BRAIN?

WORKSHOP OBJECTIVES

Define five substance use benchmarks that

qualify the danger threshold when substance

abuse has been identified

Identify adult functioning most severely impacted

by Substance Use Disorders (SUD)

Explore how caregiver protective capacities are

compromised by Substance Use Disorders

QUALIFYING THE DANGER THRESHOLD

1. HOW LONG HAVE SUBSTANCES BEEN ABUSED?

2. HOW SEVERE IS THE CONDITION?

3. HOW LIKELY IS USE TO CONTINUE WITHOUT INTERVENTION?

4. HOW PERVASIVE IS THE CONDITION?

5. WHAT IS THE IMPACT ON THE FAMILY?

WHERE DO THE “QUALIFIERS” EVENTUALLY

LEAD US?

HOW LONG HAVE SUBSTANCES BEEN

ABUSED?

HOW SEVERE IS THE CONDITION?

HOW LIKELY IS USE TO CONTINUE WITHOUT INTERVENTION?

HOW PERVASIVE IS THE CONDITION?

WHAT IS THE IMPACT ON THE

FAMILY?

COMPROMISED

ADULT

FUNCTIONING

DIMINISHED

PROTECTIVE

CAPACITIES

IDENTIFICATION OF

DANGER THREAT

HOW LONG HAVE SUBSTANCES BEEN

ABUSED?

HOW SEVERE IS THE CONDITION?

HOW LIKELY IS USE TO CONTINUE WITHOUT

INTERVENTION?

HOW PERVASIVE IS THE CONDITION?

WHAT IS THE IMPACT ON THE FAMILY?

ONE OR BOTH PARENTS’/

CAREGIVERS’ BEHAVIOR IS

DANGEROUSLY IMPULSIVE

OR THEY WILL NOT/

CANNOT CONTROL THEIR

BEHAVIOR

NO ADULT IN THE HOME

WILL PERFORM PARENTAL

DUTIES AND

RESPNSIBILIITES

COMPROMISED

ADULT

FUNCTIONING

DIMINISHED

PROTECTIVE

CAPACITIES

ACUTE

WITHDRAWAL

HOW DOES DANGER MANIFEST

DURING . . .?

POST ACUTE

WITHDRAWAL

ACTIVE

USE

HIJACKING: ‘CATCH & RELEASE’

ACTIVE

USE LEARNING

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTION

SHORT TERM MEMORY

HIJACKING: LONG-TERM

CONSEQUENCES

ACTIVE

USE

Dopamine is the primary neurotransmitter

involved in reward and motivation pathways

and is central to understanding substance

abuse.

The Salience Theory of Dopamine: A Matter of Attention Gone Awry

Dopamine’s major

role…

”HEY, PAY ATTENTION

TO THIS!”

Dopamine’s major role…

”HEY, PAY ATTENTION TO

THIS!”

ALERTS ABOUT FOOD,

SEX, DANGER AND PAIN

The Salience Theory of Dopamine: A Matter of Attention Gone Awry

Dopamine’s major

role…

”HEY, PAY ATTENTION

TO THIS!”

DRUGS

5 – 10XALERTS ABOUT FOOD,

SEX, DANGER AND PAIN

The Salience Theory of Dopamine: A Matter of Attention Gone Awry

Dopamine’s major

role…

”HEY, PAY ATTENTION

TO THIS!”

DRUGS

5 – 10X

ALERTS ABOUT FOOD,

SEX, DANGER AND PAIN

BILATERAL PROCESS

D2

X D2X

D2

X

XX

XX

X

D2

X

X

XX

X

X

X X

X

Reduction in natural

production

Decrease D2 Sites

Increase receptor

sites

D2

D2

D2

x

NEUROADAPTATION

SINGLE

USE EVENT

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTION

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

‘CATCH & RELEASE’

HIJACKING

MULTIPLE

USE

EVENTS

LEARNING

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTION

SHORT TERM MEMORY

“Ms.

Smith,

your

court

hearing

is

tomorrow

morning

at

9:00a.m.

You’re

first

on

the

docket

so

it’s

important

that

you’re

on

time.”

“Ms.

Smith,

your

court

hearing

is

tuesday

morning

at

8:00a.m.

You’re

first

on

the

docket

so

it’s

important

that

you’re

on

time.”

“I can’t believe that S.O.B.

took my last ‘Molly’!”

”Damn…’l’ll have to pawn the

TV!”

”I need that money, Mike

better pay me back today!”

QUALIFYING THE DANGER THRESHOLD

1.HOW LONG HAVE SUBSTANCES BEEN ABUSED?

BOOKED AND RELEASED vs. INCARCERATED

ARRESTED DEVELOPMENT:

EXECUTIVE FUNCTIONS

LEARNING…PLANNING…INITIATING ACTION…DECISION MAKING…JUDGMENT…

PROBLEM SOLVING…EMOTION…SOCIAL BEHAVIOR…SHORT TERM MEMORY

ARRESTED DEVELOPMENT:

EXECUTIVE FUNCTIONS

TEMPORARILY

INCAPACITATED

ACTIVE USE

UNDER-DEVELOPED

PREFRONTAL CORTICAL

SYSTEM

HIJACKED

NEUROBIOLIGCAL

PROCESS

OR?

Developmental Disorder: Addiction starts early!

QUALIFYING THE DANGER THRESHOLD

2. HOW SEVERE IS THE CONDITION?

S

E

V

E

R

I

T

Y

SUBSTANCE USE DISORDERS

DSM-5

E V E R E 6+

M O D R A T E 4-5

M L D 2-3

LOSS OF CONTROL

NUMBER OF TIMES USED LARGER AMOUNTS OR

FOR LONGER THAN INTENDED

REPEATED ATTEMPTS TO QUIT OR CONTROL USE

TOLERANCE

MARKEDLY MORE NEEDED TO OBTAIN EFFECT

MARKEDLY DIMINISHED EFFECT USING SAME AMOUNT

WITHDRAWAL SYMPTOMS

OVERDOSE EVENTS Emergency opioid antagonist

Stress the importance of having naloxone

kits readily available to individuals,

friends and family members!!!

NARCAN Nasal Spray

S A V E – A – L I F E

N

A

L

O

X

O

N

E

QUALIFYING THE DANGER THRESHOLD

3. HOW LIKELY IS USE TO CONTINUE WITHOUT

INTERVENTION?

I

N

T

E

R

V

E

N

T

I

O

N

ASAM

LEVEL

OF

CARE

RESIDEN IAL/INPATIENT

OU PATIENT

EARLY I TERVENTION

INTENSI E OUTPATIENT (PARTIAL

INTENSIVE NPATIENT (MEDICALLY MANAGED)

AMERICAN

SOCIETY OF

ADDICTION

MEDICINE

HOSPITALIZATION)

3 CRITICAL INTERVENTION CONSIDERATIONS

1. ASSEMENT OF PROGRESSION

Discharge Status last program attended

Recovery history

What have they tried since . . .what are they doing now

Tx1 NOW Tx?

3. CHALLENGES/BARRIERS TO Tx

Tx2 Tx3

2. ASSEMENT OF STABILITY

What are they doing now

Current supports

QUALIFYING THE DANGER THRESHOLD

4. HOW PERVASIVE IS THE CONDITION?

PERVASIVENESS

POST ACUTE

WITHDRAWALACTIVE USE

COMPROMISED

EXECUTIVE

FUNCTIONING

POST-ACUTE

WITHDRAWAL

SYMPTOMS

PERVASIVENESS

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

ANXIETY/PANIC ATTACKS

IRRITABILITY

DEPRESSION/SUICIDAL THOUGHTS

FATIGUE/INSOMNIA

MEMORY LOSS

INABILITY TO CONCENTRATE

OBSESSIVE THOUGHTS

CRAVINGS/OBSESSOINS

ANHEDRONIA

SUDDEN MOOD SWINGS

1 WEEK – 2 YEARSACTIVE

USE

QUALIFYING THE DANGER THRESHOLD

5. WHAT IS THE IMPACT ON THE FAMILY?

DSM-5 CRITERIA DIMINISHED PROTECTIVE

CAPACITIES

QUALIFYING THE DANGER THRESHOLD

DSM-5 CRITERIA RELATED

TO COMPROMISED

ADULT FUNCTIONING

DIMINISHED PARENTAL

PROTECTIVE CAPACITIES

BEHAVIORAL (10)

COGNITIVE (7)

EMOTIONAL (7)

FIVE OF ELEVEN

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9

5. Role obligation failure

6. Continued use despite social/interpersonal

problems

7. Sacrificing activities to use or because of use

8. Use in situations where it is hazardous

9. Continued use despite physical or psychological problem caused or exacerbated by use

S A F E Y

S A F T Y

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9

“Parentified” child

Couch-surfing

Extended unemployment

Family made arrangement

S A F E Y

S A F T Y

5. Role obligation failure

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9S A F E Y

S A F T Y

6. Continued use despite

social/interpersonal problems

Over/Under functioning

Relationship difficulties

RELATIONSHIP DIFFICULTIES Plays the “Sympathy Card”

Tries to make you angry

ESTABLISHING COMPETENCE and

MAKING A CONNECTION

“POOR ME…”

“POOR ME…”

“POUR ME ANOTHER DRINK”

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9S A F E Y

S A F T Y

6. Continued use despite

social/interpersonal problems

Over/Under functioning

Relationship difficulties

Family “cut-offs”

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9S A F E Y

S A F T Y

7. Sacrificing activities to use or

because of use Loss of caregiver-child interactions

Loss of quality time with partner

Missed celebratory events

Loss of “family traditions”

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9S A F E Y

S A F T Y

8. Use in situations where it is

hazardous

DUIs

Use at work

Use knowing the likelihood of drug

testing - use during pregnancy/on probation/open investigation/under

supervision

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

DSM-5 Criteria

FFA

Adult Functioning

5 - 9S A F E Y

S A F T Y

9. Continued use despite physical or

psychological problem caused or

exacerbated by use

Overdose event

Hospitalizations

Another overdose event

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E TExecutive

Functioning

FFA

Protective Capacities

S A F E Y

S A F T Y

BEH

COG

EMO

DIMINISHED PROTECTIVE

CAPACITIES

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

Executive Functioning

FFA

Protective Capacities

2. The parent/caregiver takes action.

3. The parent/caregiver demonstrates impulse control.

S A F E Y

S A F T Y

BEH

#2

#3

The parent/caregiver TAKES ACTION.

BEHAVIORAL PROTECTIVE CAPACITY

• People who proceed with a positive course of action.

• People who take necessary steps to complete tasks.

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

The parent demonstrates IMPULSE CONTROL.

BEHAVIORAL PROTECTIVE CAPACITY

• People who think about consequences and act accordingly.

• People who are able to plan.

This refers to a person who is deliberate and careful; who acts in managed and self-controlled ways.

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

Executive Functioning

FFA

Protective Capacities

1. The parent/caregiver plans and is able to

articulate a plan to protect children.

S A F E Y

S A F T Y

COG

#1

The parent PLANS and is able to ARTICULATE A PLAN to protect child.

COGNITIVE PROTECTIVE CAPACITY

This refers to the thinking ability that is evidenced in a reasonable, well-thought-out plan.

• People who are realistic in their idea and arrangements about what is needed to protect a child.

• People whose awareness of the plan is best illustrated by their ability to explain it and reason as to why it is sufficient.

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

S

E

V

E

R

I

T

Y

A F E T Y

S A F T Y

S A F E T

Executive Functioning

FFA

Protective Capacities

5. The parent/caregiver displays concerns for the

child and the child’s experience and is intent on

emotionally protecting the child.

7. The parent/caregiver expresses love, empathy

and sympathy toward the child.

S A F E Y

S A F T Y

EMO

#5

#7

EMOTIONAL PROTECTIVE CAPACITY

• People who show compassion through sheltering and soothing a child.

• People who are calm, pacify, and appease a child.

The parent DISPLAYS concerns for the child and the child’s experience and is intent on emotionally protecting the child.

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

EMOTIONAL PROTECTIVE CAPACITY

• People who relate to, can explain, and feel what a child feels, thinks and goes through.

The parent EXPRESSES LOVE, EMPATHY AND SENSITIVITY TOWARD the child.

This refers to active affection, compassion, warmth, and sympathy.

LEARNING

PLANNING

INITIATING ACTION

DECISION MAKING

JUDGMENT

PROBLEM SOLVING

EMOTIONS

SOCIAL BEHAVIOR

SHORT TERM MEMORY

TARGETING ATTENTION

PARENT – CHILD

ATTACHMENT

Repeated exposure to addictive substances reduces parents’ dopaminergic response to stress,

resulting in extreme distress and vulnerability to negative emotions when caring for distressed

children.

Dopamine, along with other biological mechanisms, activates the neural pathways necessary for

parents’ motivation to bond with, nurture, and protect offspring. Once “hi-jacked” drug produced

dopamine competes with and impedes capacity for positive caregiving.

PARENTING DOUBLE WHAMMY

Parents who are substance-involved are more likely

to:

• Decreased attentiveness and engagement with their children

• More authoritarian parenting

• Dysfunctional or harsh disciplinary practice

• Increased vulnerability to negative

emotions triggered by crying, attachment

challenges, poor suckling or difficulty eating

DECREASED ATTENTIVENESS AND

ENGAGEMENT WITH THEIR CHILDREN

THERAPEUTIC PARENTING

INTERVENTIONS

SKILL-BASED PARENTING ATTACHMENT-BASED PARENTING

INFANTS AND VERY YOUNG CHILDREN

REPEATED INTENSE EMOTHONAL EXPERIENCES

FOCUS ON CHILD’S ATTACHMENT NEEDS

FOCUS ON QUALITY OF INTERACTION

MOTHERS AND TODDLERS PROGRAM (MTP)

ATTACHMENT AND BIOBEHAVIORAL

CATCHUP (ABC)

CIRCLE OF SECURITY PARENTING

PREVENTION(CoS)

MINDING THE BABY (MTB)

CHERISH THE FAMILY (CTF)

OLDER CHILDREN

COGNITVE BEHAVIORAL COMPONENTS

EXPLORE THINKING ABOUT PARENTING

TAUGHT NEW PARENTING BEHAVIORS

INCREDIBLE YEARS,

PARENT-CHILD INTERACTION THERAPY

PARENT MANAGEMENT TRAINING

TRIPLE P POSITIVE PARENTING PROGRAM

CRITICIZED FOR NOT ATTENDING TO THE

EMOTIONAL QUALITY OF CHILD-PARENT

RELATIONSHIPS

Thank you!John S. Harper

Manager

Child Protective Investigations Policy and Practice Unit

Office of Child Welfare

Florida Department of Children & Families

(850) 717-4643

john.harper@myflfamilies.com